Kaleidoscope Level II

Kaleidoscope Level II - Registration Form

1. Participants are responsible for reserving their hotel rooms and the costs.
2. Upon receipt of registration and payment, a confirmation will be emailed to you.
3. A cost of $50.00 will be charged to your credit card.

**Every participant should bring his/her Practice Manual and one IFSP that he/she developed with confidential information removed or “blacked out.**

**All Fields are Required

Name:

Agency Name:

Street Address:

City:

State:

Zip Code:

Telephone:

Email Address:

Date certified as an EI Provider:

Date of successful completion of KI:

Accommodations (Dietary/Access):

Please select the following dates/location from the dropdown menu for training.

Training Date and Location:

Questions? Call Nicole Rada at (804) 827-0200 or email at ncrada@vcu.edu

Note: for an address to be valid you must enter data for street address, city, state, and zip code.

The Partnership for People with Disabilities is a university center for excellence in developmental disabilities at Virginia Commonwealth University. VCU is an equal opportunity/affirmative action university providing access to education and employment without regards to age, color, national origin, gender, religion, sexual orientation, veteran’s status, political affiliation or disability. If alternative formats of this document are needed, please contact the Partnership for People with Disabilities at 804/828-3876 or 800/828-1120 (TDD Relay).